I am a physician, financial planner, educator, and I love to tell great stories. The world is too complicated and doesn’t have to be that way. The goal for this blog is to bring simplicity to the two subjects I know best – financial planning and medicine.
My background - Med School at University of Mississippi and residency at the Medical College of Virginia. I taught at the University of Florida and worked in various emergency departments in the Jacksonville area.
In trying to find a financial planner, I went back to school for fun and found another passion. I founded Life Planning Partners, Inc. in 2004 and felt like I haven’t had a job since. I began sharing stories on the interplay of my two professions and am grateful for audiences all over the country who want to hear my message about medicine, money, and keeping it simple. Please join the conversation.

5/03/2012 @ 10:55AM1,979 views

What Happens to the Train That Left The Station on Obamacare?

As conference season heats up for financial planners, I’m on the road again sharing particulars of the Affordable Care Act. There is still much education to provide, as many important parts of the law have been implemented. In fact, most of the train has left the station.

This week I spoke in Las Vegas to an inquisitive group of very seasoned professionals and financial planning instructors. After my session, one professor of financial planning confessed he knew only about 5% of the information I discussed in my talk. He stated, “Everyone gives the same polarized sound bites.” He wished more would talk objectively about the scope of the problems in health care and acceptable solutions. If this respected professor knows so little, what does that portend for the rest of the country?

At the beginning of my sessions, I spend about ten minutes providing an overview of the ten titles within the law. I stress that most of the “sound bites” come only from Title One, which covers health insurance. As I go through the rest of the law, I ask for a show of hands to get an idea of how many people are familiar with each of the provisions.

The current high risk pools where the previously uninsurable can now get insurance coverage? About 10% heard something about them.

How many knew about www.healthcare.gov? This website is the future of the health insurance exchange, where people will shop for their insurance coverage. It also covers preventive care, tracks quality of care measures, offers navigation of the health care system, and provides details about the Affordable Care Act. Only three people in the audience had looked at the site.

How many understood the changes in health care delivery – accountable care organizations, medical care homes, changes in payer models, rebuilding of primary care? Not one attendee. Or no one who would admit they knew anything.

I shared how much of the Affordable Care Act has already been implemented. Creating that list made me stop and think – if the entire law is repealed, what happens to all that has been implemented and the billions of dollars already spent? A small part of what has been enacted so far:

High risk pools – will these all of a sudden be stopped, and people who now count on this coverage once again be uninsured?

Preventive care for individuals - entirely too much money goes toward end stage care, when preventive education has the potential to provide more bang for the buck. There are some problems with how prevention is being implemented, but this is a work in progress that needs to continue.

Guaranteed issue insurance for children – although greater attention has been paid to problems such as attention deficit disorder, depression, asthma, and childhood obesity, these problems and labels basically made many children uninsurable. Should children not have access to coverage because adults feel the need to stick labels on them that may affect them for the rest of their lives? At least cover them until they are adults.

Prohibit rescinding coverage – one thing that makes me nervous about a total free market system is that many insurers have proven in the past they cannot be trusted to do the right thing. Should a woman newly diagnosed with breast cancer have her coverage cancelled because she forgot to disclose a previous case of acne? These shenanigans occurred too frequently before the ACA was passed.

Rebuilding primary care workforce – a strong primary care workforce provides better and more cost effective care, and we have done a great job of decimating our primary care workforce through our fee for service model. It will take money and time to reestablish a strong primary care base. In Family Medicine, the number of residency positions available and positions filled continue to increase after passage of the ACA. Too few physicians enter primary care, and once all questions regarding the ACA are answered, maybe we will get the exponential growth that is needed.

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If they don’t fix the problems, it will all fall apart and they will be forced to fix the problems. By speaking out, maybe they’ll hear us and get to work on it before it becomes a disaster. I’m optimistic.

Another very worthwhile piece. Providing instruction in a college Employee Benefits class this semester has been a challenge – trying to decipher what has been implemented, what remains to be implemented, and what might occur given the U.S. Supreme Court case. Carolyn’s incredible articles have been so valuable to both me and to my students. Keep up the great work … we all have so much more to learn about the rapid changes occurring in our health care system, and their implications for employers and individuals alike.

This is a very interesting question. Hospitals and physicians are working fervently to create the ACO model, and many are very nervous about the time and energy they have put forward without knowing if the ACA will stand. Either way, if the law is entirely abandoned, I think many will call for change to keep the valuable parts of reform in place. Who needs TV when we can watch health care reform in action?

There are many good aspects of the ACA. I think the prohibition against rescinding coverage and the requirement for coverage of pre-existing conditions are essential. I don’t see how any changes to the health care system prior to the ACO could be considered imprvovements without addressing these issues.

I have problems with the ACA from several men’s health perspectives.

1. No well-men’s coverage. Although preventative services are covered, the office visit itself to obtain the services may not be covered. That can be quite expensive and could prevent men from going in the first place. In fact, men are 24% less likely to visit a doctor than are women, according to the Agency for Healthcare Research and Quality. Men don’t need any more discouragement to visit the doctor.

2. No contraceptive coverage for men. This has made vasectomy in many cases unaffordable. Much healthcare insurance has gone to high deductible plans, at least in part, according to the providers, to help pay for the new coverages. This makes contraception for men – at this time only vasectomy but that could change in the future – fully deductible. When I researched my plan, for example, with a $3000 deductible and the full cost of a vasectomy from my provider being $4600, the cost to me of a vastectomy will be $3000, until the deductible is satisfied. So there is nothing affordable about a vasectomy for me in Affordable Care Act. This will have the unfortunate effect of make female sterilization the preferred procedure, where it should not be. Additionally, when the time arrives that advanced male contraception becomes available, it may fail in the marketplace; who would buy advanced male contraception when female contraception is free?

3. No domestic violence screening. Although more women than men are victims of domestic violence, according to the CDC 1 in 7 men are domestic violence victims. That is a substantial number to leave as collateral damage from neglect in the ACA.

4. No coverage for prostate cancer screening. Although the US Preventative Services Task Force has questioned the value of PSA screening, the medical community is divided on the issue. The American Cancer Society still states that the evidence is not conclusive. And even the USPSTF recommendations indicate that the choice should be up to individual men after being informed of the risks and benefits. However, there is no true choice when cost is involved as coercion. This preventative service should be covered at no cost share if a man makes the choice to have it.

So while we can acknowledge the good aspects of the ACO, we must also acknowledge its shortcomings. Unfortunately, I am pessimistic these shortcomings will be addressed, as congress has a history of neglect of men’s health.

You make some good points, and as a country, we really need to decide what we will use taxpayer money for. If the recommendations you suggest are cost effective, than they should be strongly considered.

Talking only in cost effectiveness terms, we can have the following discussion.

1. Well men’s coverage would most certainly be considered cost effective under one of the key assumptions of the ACA – prevention is cheaper than treatment. So if the law puts obstacles in the way of men seeking preventation, they will come back in for treatment, at much higher cost.

2. For male contraception – at this time only vasectomies – the cost of an unplanned pregnancy is greater than a planned one, and the cost of a vasectomy should be less than a tubal ligation. But the ACA law as it is now structured distorts that – tubal ligation will be cheaper for the consumer that a vasectomy. The cost difference will be paid by premium payers and tax payers.

3. For domestic violence screening, I can’t make a claim about the financial impact of violence on males, but will instead have to rely on experts who claim that violence propagates violence – the violence cycle. That accounts for costs to public safety.

4. For prostate cancer screening, the verdict is certainly out on costs for this one. Whether screening would prevent the costs of expensive end stage treatment is the essence of the discussion. Furthermore, whether cost considerations effectively mitigate human suffering remains an unexplored medical topic.

All this being said about costs, let’s get real. The motivation in the ACA about the better preventative care services available to women than those available to men has nothing to do with costs and has everything to do with politics. It is about what measures are going to get more votes for whom. Women’s health lobbies in Congress are better and more powerful than are Men’s health lobbies. Women pay attention to healthcare issues and men don’t. I know that. No one reading my comments should be surprised to learn that I am involved in Men’s health lobbies.

I think that the best discussions about the ACA and the correct approach to health care recognize that gender equity without the inequities now in place is essential to achieving the correct healthcare solution for the citizens of this country.